Constrictive pericarditis after myocardial infarction.

Constrictive pericarditis developed in a 55 year old man two years after transmural myocardial infarction complicated by severe acute pericarditis. Pericardiectomy was successful. Although this very rare late complication of myocardial infarction has been reported as a sequela of frank anticoagulant induced haemopericardium, in this case there was no clinical evidence of such an association.

Preoperative clinical predictors of long term survival in mitral stenosis: analysis of 200 cases followed for up to 27 years after closed mitral valvotomy.

Two hundred patients aged 17-40 years undergoing closed mitral valvotomy during 1955-60 were studied by actuarial survival analysis. The period of follow up was 22-27 years. The following preoperative features were found to be independent predictors of long term survival: sinus rhythm (p less than 0.05); pulmonary arterial pressure below systemic pressure (p less than 0.01); absence of congestive cardiac failure (p less than 0.01) and pure mitral stenosis (p less than 0.01). A better long term survival was found for mitral valvotomy with a Tubb's dilator than finger splitting or Brock's method. The presence of calcification at the time of valvotomy adversely affected survival (p less than 0.01). Anticoagulation improved survival (p less than 0.01). It is concluded that closed mitral valvotomy gives good results if performed before the onset of established atrial fibrillation and congestive cardiac failure and that all patients should have anticoagulation. These results have important implications for selection of patients in countries with limited facilities for open heart surgery.

Primary meningococcal pericarditis with tamponade.

A case of primary purulent meningococcal pericarditis presenting with chest pain, hypotension and cardiac tamponade followed by oliguric renal failure is reported. Treatment with antibiotics and surgical drainage was successful.

Coronary embolism in valvular heart disease.

Coronary embolism is considered to be rare but recent evidence suggests that it may be underdiagnosed, and implicated in acute myocardial infarction associated with angiographically normal coronary arteries. Twenty-six patients were studied. In six, coronary embolism was a primary cause of death confirmed at autopsy. In 20 patients, 23 episodes of coronary embolism were diagnosed clinically. The left coronary system was occluded in 65 per cent, transient electrocardiographic changes occurred in 30 per cent, and either no history or an atypical history of acute myocardial infarction occurred in 29 per cent. Other systemic emboli occurred in 25 per cent. Aortic valve lesions were present in 70 per cent and combined mitral and aortic valve disease in 55 per cent of the patients. The incidence of coronary risk factors was low. Sequelae included increased dyspnoea (35 per cent), ventricular aneurysm (25 per cent) and cardiac failure (12 per cent). Angina rarely followed acute myocardial infarction.

Echocardiography in combined discrete and hypertrophic subaortic stenosis.

A 10-year-old boy with discrete subaortic stenosis had coexisting abnormal systolic anterior motion of the mitral valve, demonstrated by echocardiography, a sign normally taken as indicating the presence of idiopathic hypertrophic subaortic stenosis. Surgical removal of a fibromuscular diaphragm abolished the echocardiographic signs of discrete subaortic stenosis but abnormal systolic anterior motion of the mitral valve persisted. A severe low cardiac output state complicated immediate recovery after removal of the left ventricle outflow obstruction, and was overcome only with considerable difficulty. The presence of hypertrophied septal muscle, and the associated small left ventricular cavity size, was thought to be the immediate cause of these problems, so that recognition of marked septal hypertrophy, together with abnormal anterior systolic movement of the mitral valve, should serve as a warning that similar difficulties are likely to bae encountered by other patients, after removal of the obstruction in subaortic stenosis. In our experience other forms of left ventricle outflow tract obstruction have not been found to show such a marked degree of asymmetric septal hypertrophy, but this does not mean it may not occur.

Echophonocardiography in diagnosis of mitral paravalvular regurgitation with Björk-Shiley prosthetic valve.

The echophonocardiographic features in three patients with a mitral Björk-Shiley prosthesis and paravalvular regurgitation are presented. The characteristic features are an early diastolic humping of the Björk-Shiley disc echo, associated with normal rather than paradoxical septal motion, and a reduced A2-MVO interval. The diagnosis was confirmed at operation in one patient, at cardiac catheterisation and operation in the second, and at necropsy in the third. These features were abolished by surgical correction of the leak in both operated cases.

Interatrial abscess.

A large abscess of the interatrial septum developed during the course of acute bacterial endocarditis affecting the aortic valve. Septic involvement of the cardiac conducting system produced atrioventricular dissociation, and subsequent abscess rupture resulted in an aorto-right atrial communication. The clinical presentation of this rare complication of acute bacterial endocarditis is correlated with the post-mortem findings.

Noonan's syndrome and cyanotic congenital heart disease. A report of 4 cases and review of the literature.

The clinical features of four adult patients with Noonan's syndrome and cyanotic congenital heart disease are presented. These findings, together with those of previously reported cases, illustrate the wide spectrum of cardiac anomalies that may be associated with the multiple somatic abnormalities of Noonan's syndrome.

Plasma catecholamine levels and cardiac rhythm before and after cardiac catheterisation.

Plasma catecholamine concentrations were estimated in a group of 17 fasting patients immediately before and 3 days after cardiac catheterisation. At both times electrocardiograms were recorded and blood pressures, heart rates, and respiration rates measured. Control catecholamine values were established in a group of 10 male and 10 female volunteers, bled at the same time of day under the same conditions of nutrition and posture. Levels of adrenaline and noradrenaline were increased substantially before catheterisation; 3 days later, the values were comparable to those of the control group, though still marginally higher. The increments in catecholamine levels were independent of sex and of the presence or otherwise of persistent supraventricular arrhythmias. In spite of the considerably raised catecholamine levels, electrocardiographic patterns remained unchanged, as did the other physiological values. The absence of any relation between enhanced catecholamine secretion and physiological effects is considered to be the result either of enhanced parasympathetic activity or of adaptation to a prolonged period of stress.